Medication provision spurs anger

Budget proposal would no longer allow doctors to override changes

Editor's note: An earlier version of this story incorrectly defined the scope of a proposal to eliminate so-called "prescriber prevails" provisions in Medicaid. The proposed change applies only to Medicaid fee-for-service plans.

Albany

Patient advocates expressed outrage Monday over what they call a "surprise" provision among Gov. Andrew Cuomo's 30-day budget amendments that would strip doctors of the final say in disputes with Medicaid over which medicine a patient should be prescribed.

Under the proposal, Medicaid patients could be switched from their current medications to less expensive drugs, and medical practitioners would no longer be able to override that decision. The change would apply to all fee-for-service Medicaid plans.

The amendment is tied to passage of the bulk of the proposed $17.1 billion state share of the budget for Medicaid, the government-sponsored health insurance program for low-income Americans.

The state Health Department estimates that removal of the so-called "prescriber prevails" rule in Medicaid would save the state $4.1 million in the upcoming fiscal year and $5.5 million in the year beginning April 2016.

Patient advocates said those savings would be erased by the cost of hospitalizations and other medical care required to treat patients whose conditions worsened due to complications from switching medication.

Of particular concern, opponents said, are patients with mental illness, cancer and autoimmune diseases like lupus. Doctors must often try multiple drugs in different combinations with such patients to achieve the desired benefits. Once an effective balance is found, patients and doctors want to stick with what works.

Pharmaceutical companies, whose brand-name drugs would be prescribed less often under the proposed rule, also oppose the change. Medicaid already receives deep discounts on the price of prescriptions, said Priscilla VanderVeer, a spokeswoman for Pharmaceutical Research and Manufacturers of America, a lobbying group. PhRMA cites an analysis that shows most doctors are already unwilling to jump over required bureaucratic hurdles to override a Medicaid decision, unless they feel strongly their patients require a certain drug.

Assembly Health Committee Chair Richard Gottfried, D-Manhattan, said those obstacles to prescribing off the preferred drug list were intentional, and the result of more than two years of wrangling between legislators and the administration of former Gov. George Pataki.

"It creates enough of a speed bump to encourage prescribers to stick to the Medicaid preferred drug list or a Medicaid managed care company's formulary, but still gives a prescriber who feels strongly the ability to prevail," he said.